DislocationDislocationDislocationDislocation is a complete is a complete separation of the separation of the articular surfaces with articular surfaces with fixation in an abnormal fixation in an abnormal position.position.Anterior dislocation of Anterior dislocation of the condyle in which the the condyle in which the normal anatomic normal anatomic relationships within the relationships within the joint have been joint have been completely disrupted completely disrupted occurs with the condyle occurs with the condyle displaced and fixed displaced and fixed anterior to the articular anterior to the articular eminence. eminence.

The key terms used include The key terms used include hypermobility, acute dislocation, long hypermobility, acute dislocation, long dislocation, recurrent dislocation and dislocation, recurrent dislocation and habitual dislocation. habitual dislocation. Subluxation is substituted for the Subluxation is substituted for the term term dislocationdislocation where dislocation is where dislocation is incomplete .incomplete .luxation and dislocation are luxation and dislocation are synonymous.synonymous.

Dislocation can occur as a single acute Dislocation can occur as a single acute event or as chronic recurring episodes.event or as chronic recurring episodes.Dislocations which take place Dislocations which take place repeatedly and which last for short or repeatedly and which last for short or long interval are referred to long interval are referred to as as Recurrent Recurrent dislocation.dislocation. A dislocation that remains locked A dislocation that remains locked anteriorly for several days years is an anteriorly for several days years is an old or old or long-standing long-standing dislocation.dislocation. The term The term choric dislocationchoric dislocation is most is most appropriately used in those cases appropriately used in those cases where the patient is able dislocate and where the patient is able dislocate and reduce at will.reduce at will.

Classification of Classification of Temporomandibular jointTemporomandibular joint

I. Temporomandibular joint disordersI. Temporomandibular joint disordersa. Deviation in forma. Deviation in form1. Articular surface defects1. Articular surface defects2. Disc thinning and perforation2. Disc thinning and perforation

b. Disc displacementsb. Disc displacements1. Disc displacement with reduction1. Disc displacement with reduction2. Disc displacement without reduction2. Disc displacement without reduction

c. Displacement of disc-condyle complexc. Displacement of disc-condyle complex1. Hypermobility1. Hypermobility2. Dislocation2. Dislocation

d. Inflammatory conditionsd. Inflammatory conditions1. Capsulitis and synovitis1. Capsulitis and synovitis2. Retrodiscitise.2. Retrodiscitise.

E.Degenerative diseasesE.Degenerative diseases 1.0steoarthrosis1.0steoarthrosis 2. Osteoarthritis2. Osteoarthritis 3. Polyarthritides3. Polyarthritides

f. Ankylosisf. Ankylosis 1. Fibrous1. Fibrous 2. Bony2. Bony

II.masitatory muscles disorderII.masitatory muscles disorder1. myositis1. myositis2. reflex muscle splinting2. reflex muscle splinting3. Muscle spasm3. Muscle spasmb. Chronicb. Chronic1. Myofascial pain1. Myofascial pain2. Muscle contracture2. Muscle contracture3. Hypertrophy3. Hypertrophy4. Myalgia secondary to systemic disease4. Myalgia secondary to systemic disease

III. Congenital and developmental disordersIII. Congenital and developmental disordersa. Condylar hyperplasiaa. Condylar hyperplasiab. Condylar hypoplasiab. Condylar hypoplasiac. Aplasiac. Aplasiad. Condylolysisd. Condylolysise. Neoplasmse. Neoplasmsf. Fractures.f. Fractures.

SubluxationSubluxation

Condylar subluxationCondylar subluxation is an incomplete is an incomplete joint the articular surfaces maintain joint the articular surfaces maintain partial contact and the condyle is able partial contact and the condyle is able to return to the glenoid fossa to return to the glenoid fossa voluntarily or aided by self voluntarily or aided by self manipulation.manipulation.

The condition is related to internal The condition is related to internal derangement as the open, incomplete derangement as the open, incomplete and transient dislocationand transient dislocation

LigamentsLigamentsThe The activity and condition of the activity and condition of the ligamentsligaments associated with the associated with the temporomandibular joint are temporomandibular joint are important considerations in important considerations in dislocation.dislocation.The temporomandibular The temporomandibular ligament and capsules ligament and capsules remained taut in all mandibular remained taut in all mandibular movements and maintained the movements and maintained the mandible in articulation the mandible in articulation the cranial basecranial baseOpening movements of the Opening movements of the mandible caused the mandible caused the stylomandibular ligaments and stylomandibular ligaments and sphenomandibular to become sphenomandibular to become slack and flodedslack and floded. .

PathophysiologyPathophysiology

Acute anterior Acute anterior dislocation is dislocation is precipitated by either precipitated by either intrinsic or extrinsic intrinsic or extrinsic traumatrauma..

A A wide yawnwide yawn is a is a frequent cause of frequent cause of spontaneous (intrinsic) spontaneous (intrinsic) dislocation.dislocation.

Other forms of intrinsic Other forms of intrinsic events such as events such as vomiting,singing vomiting,singing laughing,screaming, laughing,screaming, wide biting,&seizures.wide biting,&seizures.

Extrinsic traumatic dislocation is due Extrinsic traumatic dislocation is due to violence which to violence which forces the condyle forces the condyle out of the fossa.out of the fossa.

External force such as External force such as a blow to thea blow to the mandiblemandible,usually with the mouth in an ,usually with the mouth in an open position, can result in mandibular open position, can result in mandibular dislocation.dislocation.

Manipulation of the jaw during Manipulation of the jaw during intubation for general anaesthesia, intubation for general anaesthesia, endoscopy & dental extraction is endoscopy & dental extraction is another extrinsic cause.another extrinsic cause.

Laxity of ligaments& Laxity of ligaments& capsulecapsule & & abnormalities of abnormalities of skeletal form are skeletal form are predisposing factors in predisposing factors in both acute & chronic both acute & chronic forms of dislocation.forms of dislocation. Looseness of the Looseness of the capsule and ligaments capsule and ligaments can occur from can occur from inadequate healing inadequate healing after injuries, after injuries, hypermobility& from hypermobility& from longstanding longstanding degenerative joint degenerative joint disease.disease.

Occlusal abnormalities and loss of Occlusal abnormalities and loss of vertical dimension from loss of vertical dimension from loss of teeth can also contribute to laxity teeth can also contribute to laxity & to the occurrence of & to the occurrence of recurrent recurrent dislocation.dislocation.

Acute dislocationAcute dislocation found the found the commonest cause to be a blow on commonest cause to be a blow on the chin with the mouth open in the chin with the mouth open in males and dental extractions in males and dental extractions in females.females.

The activity and condition of the The activity and condition of the ligaments associated with the ligaments associated with the temporomandibular joint are temporomandibular joint are important considerations in important considerations in dislocation.dislocation.

The The tempromandibular ligament tempromandibular ligament & capusle remained taut& capusle remained taut in all in all mandibular movements and mandibular movements and mantained the mandible in mantained the mandible in articulation the cranial base.articulation the cranial base.

Opening movements of the Opening movements of the mandible caused the mandible caused the stylomandibular ligaments and stylomandibular ligaments and sphenomandibular sphenomandibular to become to become slack and folded.slack and folded.

HypermobilityHypermobility

HypermobilityHypermobility of of this joint is this joint is characterized by excessive characterized by excessive anterior movement anterior movement of of the the condyle at maximum mouth condyle at maximum mouth opening without strain or opening without strain or symptoms.symptoms.Hypermobility, subluxation, Hypermobility, subluxation, and dislocation of the and dislocation of the temporomandibular joint are temporomandibular joint are interelated conditions, and interelated conditions, and hypermobility is likely a hypermobility is likely a predisposing factor.predisposing factor.

Systemic HypermobilitySystemic Hypermobility

Familial hypermobility syndromes loose-Familial hypermobility syndromes loose-jointed individuals with articular symptoms jointed individuals with articular symptoms comprise a very heterogeneous group. comprise a very heterogeneous group.

In the In the Ehlers Danlos syndromeEhlers Danlos syndrome the degree of the degree of hypermobility and the incidence of hypermobility and the incidence of dislocation are closely related.dislocation are closely related.

In this condition dislocations of the In this condition dislocations of the temporomandibular joint are often recurrent temporomandibular joint are often recurrent

Ehlers Danlos syndrome the incidence of Ehlers Danlos syndrome the incidence of temporomandibular joint dislocations was temporomandibular joint dislocations was 3.3%3.3%

Occlusal factorsOcclusal factors

Long-term overclosureLong-term overclosure and and loss of physiologic loss of physiologic vertical dimensionvertical dimension secondary to loss of secondary to loss of dentition can Contribute dentition can Contribute to subluxation & to subluxation & dislocation.dislocation.The mechanism of this The mechanism of this is thought to be that is thought to be that overclosure produces overclosure produces stretching and loosening stretching and loosening of joint ligaments and of joint ligaments and joint laxity can then lead joint laxity can then lead to to subluxationsubluxation..

Asymmetry of the Asymmetry of the condylar position due to condylar position due to mandibular malposition mandibular malposition may be caused by may be caused by occlusal interferences.occlusal interferences.Occlusal disturbances Occlusal disturbances may also be related to may also be related to Bruxism.Bruxism.Recurrent dislocationRecurrent dislocation occurs in which occurs in which extractions of bilateral extractions of bilateral distoangular, palatally distoangular, palatally inclined maxillary third inclined maxillary third molars eliminated the molars eliminated the mandibular dislocation. mandibular dislocation.

Drug-associated dislocationDrug-associated dislocation

Spontaneous dislocation Spontaneous dislocation of the mandible due to of the mandible due to extrapyramidal reactions extrapyramidal reactions to to prochlorperazineprochlorperazine..

Left facial weakness and Left facial weakness and wild facial contortions wild facial contortions occurred, followed by a occurred, followed by a unilateral mandibular unilateral mandibular dislocation. dislocation.

Psychogenic dislocationPsychogenic dislocation

HysteriaHysteria can be the cause can be the cause of of habitual dislocation habitual dislocation of of the the mandible.mandible.Ligaments are lax and repetitious Ligaments are lax and repetitious subluxation or dislocation can subluxation or dislocation can easily occur. easily occur. It is important to recognize early It is important to recognize early that habitual dislocation may be that habitual dislocation may be the presenting feature of an the presenting feature of an underlying underlying psychiatric psychiatric disturbance. disturbance. The degree and duration The degree and duration of of the the disability are out disability are out of of all Proportion all Proportion to the severity to the severity of of the injury. the injury.

DiagnosisDiagnosis A thorough A thorough History & physicalHistory & physical

examinationexamination is important to evaluate is important to evaluate properly all categories properly all categories of of dislocation.dislocation.

It is important to determine the cause It is important to determine the cause & onset & onset of of the dislocation. the dislocation.

A spontaneous intrinsic dislocation A spontaneous intrinsic dislocation only occurs in an only occurs in an anterior direction.anterior direction.

Acute, initial spontaneous and Acute, initial spontaneous and extrinsic traumatic anterior extrinsic traumatic anterior dislocations are treated differently dislocations are treated differently from chronic repetitive dislocation.from chronic repetitive dislocation.

A prior history A prior history of of local joint local joint laxity, internal laxity, internal derangements,& derangements,& other other temporomandibular joint temporomandibular joint disorders will influence the disorders will influence the outcome outcome of of treatment and treatment and must be ascertained in must be ascertained in evaluating the past history.evaluating the past history.Neurologic & mucoskeletal Neurologic & mucoskeletal disorders such as disorders such as Parkinson's disease & Parkinson's disease & epilepsyepilepsy and other and other systemic disorder of systemic disorder of hypermobility are hypermobility are important to recognize. important to recognize.

Clinical examinationClinical examinationSpontaneous dislocationSpontaneous dislocation from a wide yawn is from a wide yawn is often bilateral,but a blow to the chin with the often bilateral,but a blow to the chin with the mouth open usually create a unilateral mouth open usually create a unilateral dislocation.dislocation.Bilateral dislocationBilateral dislocation is associated with pain, is associated with pain, inability to close the mouth,tense masticatory inability to close the mouth,tense masticatory muscles, difficulty with speech, excessive muscles, difficulty with speech, excessive salivation a protruding chin and open bite. salivation a protruding chin and open bite. The The lateral pole of the condylelateral pole of the condyle produces a produces a characteristic protuberance anterior to and characteristic protuberance anterior to and below the articular eminence which can below the articular eminence which can usually be seen and palpated.usually be seen and palpated.

Unilateral dislocationUnilateral dislocation is characterized by is characterized by the mandible swung away from the side the mandible swung away from the side of dislocation. of dislocation.

The Devation produces a lateral cross The Devation produces a lateral cross and Open bite on the contra lateral side.and Open bite on the contra lateral side.

Palpation Palpation of the muscles and joints is a of the muscles and joints is a valuable aid to diagnosis.valuable aid to diagnosis.

Tenderness in the jointTenderness in the joint may indicate a may indicate a fracture,where as tenderness in the fracture,where as tenderness in the temporal fossa is more characteristic of temporal fossa is more characteristic of dislocation. dislocation.

In subcondylar fracture In subcondylar fracture fracture side is fracture side is retrusiveretrusive rather than rather than protrusiveprotrusive & the & the fractured condyle when fractured condyle when palpated does not follow the palpated does not follow the movement of the mandible. movement of the mandible. Furthermore Furthermore crepitiuscrepitius at the at the fracture site can often be fracture site can often be detected.detected.Dislocation alone is not Dislocation alone is not accompanied accompanied bybycrepitus,bleeding,steps in crepitus,bleeding,steps in the occulsion & paresthesiathe occulsion & paresthesia..Patient will have the Patient will have the sensation of free fluid in the sensation of free fluid in the joint and pain with tender joint and pain with tender edema about the joint. edema about the joint.

Radiographic examination Radiographic examination Plains flims such as Plains flims such as transcranial transcranial radiograph & lateral tomogramsradiograph & lateral tomograms are are important in the idenfication & important in the idenfication & documentation of dislocation.documentation of dislocation.Arthrographic studiesArthrographic studies with recurrent with recurrent dislocation have enlabed a dislocation have enlabed a differenation to be made between differenation to be made between meniscotemporal & meniscocondylar meniscotemporal & meniscocondylar typestypesMRI and CT scanningMRI and CT scanning would to useful would to useful to identifying ligament and capsular to identifying ligament and capsular tears and stretching.tears and stretching.Eletromyographic studiesEletromyographic studies in in dislocation and subluxction provide dislocation and subluxction provide valuable information.valuable information.

DILOCATION WITH CONDYLE ANTERIOR TO DISK & EMINENCE

Non surgical TreatmentNon surgical Treatment

The initial acute the longstanding & the The initial acute the longstanding & the chronic recurring dislocations of the chronic recurring dislocations of the mandible require different treatments.mandible require different treatments.

The The acute dislocationacute dislocation needs immediate needs immediate attention for relief of pain and anxiety and to attention for relief of pain and anxiety and to minimize damage to the joint structure.minimize damage to the joint structure.

Reduction and immobilization for 4 weeksReduction and immobilization for 4 weeks will allow damage ligaments, capsule, and will allow damage ligaments, capsule, and disk to heal. disk to heal.

However in chronic case, Immobilization does However in chronic case, Immobilization does nothing correct the problem of an unstable nothing correct the problem of an unstable jointjoint

The major problem to overcome in all The major problem to overcome in all dislocation is dislocation is muscle contractionmuscle contraction..

Treatment is different for Treatment is different for troublesome repetitive dislocation troublesome repetitive dislocation where the etiology is psychologic where the etiology is psychologic compared with systemic hyermobility compared with systemic hyermobility without psychologic implications.without psychologic implications.

Acute dislocationAcute dislocation Initial treatment is aimed at Initial treatment is aimed at reducing reducing

tension, anxiety, and muscle spasmtension, anxiety, and muscle spasm by by using the simplest methods.using the simplest methods.

A A tranquillizer or sedativetranquillizer or sedative may aid in may aid in gaining then relaxtion needed also gaining then relaxtion needed also pressure and message over coronoid pressure and message over coronoid processes can also benefit.processes can also benefit.

An impressive simple technique is used An impressive simple technique is used by by injecting local anesthetic is injectedinjecting local anesthetic is injected into the depression in the glenoid fossa into the depression in the glenoid fossa left by the dislocated condyle.left by the dislocated condyle.

ManipulationManipulation is the next step. is the next step.Hippocrates remains an effective Hippocrates remains an effective way to manipulate and reduce the way to manipulate and reduce the dislocated mandible.dislocated mandible.A common method currently used A common method currently used has the operator standing in front has the operator standing in front of the patient who is sitting with of the patient who is sitting with the head supported. the head supported. Thumbs are wrapped in gauzeThumbs are wrapped in gauze and and placed on the occlusal surfaces of placed on the occlusal surfaces of the mandibular molars or alveolar the mandibular molars or alveolar ridges.ridges.The lower border of the mandible The lower border of the mandible is grasped with the fingers and the is grasped with the fingers and the patient is encouraged to relax and patient is encouraged to relax and open in the direction of the open in the direction of the dislocation. dislocation. By pressing firmly on the molars By pressing firmly on the molars and elevating anteriorly with and elevating anteriorly with simultaneous simultaneous backward pressure backward pressure the condyle is relocated.the condyle is relocated.

Yurino's Method Yurino's Method Places the patient in a supine Places the patient in a supine position without a pillow.position without a pillow.The patient is encouraged to The patient is encouraged to relax completely while the relax completely while the operator stands near the operator stands near the patient's head and patient's head and holds the holds the body of the mandible from body of the mandible from the opposite side.the opposite side.The patient is asked to open The patient is asked to open and close the mouth and, and close the mouth and, although it is difficult to do although it is difficult to do so,it is important for the so,it is important for the patient to attempt this alone.patient to attempt this alone.

The operator moves the The operator moves the mandible up and down in mandible up and down in phase with the patient's phase with the patient's opening and closing opening and closing movements.movements.

The operator thenThe operator then locates locates the dislocated condyle with the dislocated condyle with his thumb & simultaneouslyhis thumb & simultaneously with the patient's closing with the patient's closing motion pushes it completely motion pushes it completely downward while moving the downward while moving the body of the mandible body of the mandible upward. upward.

By this procedure the By this procedure the condyle moves over the condyle moves over the articular eminence and slips articular eminence and slips into the fossa. into the fossa.

Longstanding dislocationLongstanding dislocationThe difficulty in reducing mandibular The difficulty in reducing mandibular dislocation increases proportionately dislocation increases proportionately with time with time Muscle relaxation and Muscle relaxation and manipulationmanipulation are usually successful if are usually successful if carried out immediately or within a few carried out immediately or within a few hours.hours.Reduction by forcing the mandible Reduction by forcing the mandible downward with the thumbs in the downward with the thumbs in the molar region and simultaneous upward molar region and simultaneous upward tiliting of the chin was tried first.tiliting of the chin was tried first.CondylectomyCondylectomy was the preferred was the preferred method. method.

Nonsurgical treatment of recurrent Nonsurgical treatment of recurrent dislocationdislocation

Physical therapy:Physical therapy:

The use of The use of isometric exercisesisometric exercises to to improve opening and closing patterns improve opening and closing patterns is most important. is most important.

Synchronized isometric contractionSynchronized isometric contraction exercises of masticatory opening exercises of masticatory opening muscles and their antagonists should muscles and their antagonists should be performed on a regular basis. be performed on a regular basis.

Isometric exercise similar to that described Isometric exercise similar to that described by by PoswilloPoswillo is very helpful. is very helpful.

This relatively This relatively simple exercise trains the simple exercise trains the suprahyoid musclessuprahyoid muscles to stabilize the mandible to stabilize the mandible and reduce forward movement of the condyle and reduce forward movement of the condyle in the early opening phase.in the early opening phase.

The exercise should be carried out several The exercise should be carried out several times a day for 4 weeks until dislocations are times a day for 4 weeks until dislocations are no longer a problem. no longer a problem.

Then the exercise should be done indefinitely Then the exercise should be done indefinitely once or twice a day to maintain the stability once or twice a day to maintain the stability and and to prevent a return to paranormal to prevent a return to paranormal function.function.

Symptomatic treatmentSymptomatic treatment Patients with subluxation and dislocation often Patients with subluxation and dislocation often

suffer suffer arthralgia & myalgiaarthralgia & myalgia and symptomatic and symptomatic treatment is necessary.treatment is necessary.

Analgesics and nonsteroidal anti-inflammatoryAnalgesics and nonsteroidal anti-inflammatory drugs will relieve locomotor system pain whether in drugs will relieve locomotor system pain whether in the joint, bone, tendon, ligament, or muscle. the joint, bone, tendon, ligament, or muscle.

Muscle relaxants and tranquillizersMuscle relaxants and tranquillizers are useful. are useful. An injection of a steroid such as An injection of a steroid such as methylprednisonemethylprednisone

gives excellent results in persistent synovitis in the gives excellent results in persistent synovitis in the hypermobility syndrome. hypermobility syndrome.

Long-acting corticosteroids should be avoidedLong-acting corticosteroids should be avoided as as they may lead to connective tissues atrophy and they may lead to connective tissues atrophy and weakening of collagenous tissue, which may weakening of collagenous tissue, which may contribute to increasing joint laxity.contribute to increasing joint laxity.

Occlusal treatmentOcclusal treatment

Occlusal disturbances, such as cuspal Occlusal disturbances, such as cuspal interfernces and non occlusion due missing interfernces and non occlusion due missing teeth with loss of vertical support, should teeth with loss of vertical support, should be corrected to prevent their contributing be corrected to prevent their contributing to the instability of the joint.to the instability of the joint.

However,However,appliancesappliances can be useful in those can be useful in those individuals with coexisting internal individuals with coexisting internal derangement of the disk, bruxism, and derangement of the disk, bruxism, and muscle hyperactivity.muscle hyperactivity.

Chemical CapsulorrhaphyChemical Capsulorrhaphy The injection of The injection of sclerosing agentssclerosing agents into the into the

supporting ligaments or into the Joint .supporting ligaments or into the Joint .

The objective is to produce fibrosis and The objective is to produce fibrosis and tightening of the capsular ligaments, thus tightening of the capsular ligaments, thus limiting motion of the mandible and limiting motion of the mandible and preventing subluxations and dislocations.preventing subluxations and dislocations.

The use of The use of sodium psylliate emulsionsodium psylliate emulsion in oil, in oil, alcohol,and homogeneous blood has been alcohol,and homogeneous blood has been advocated. advocated.

The disadvantange in their use is the The disadvantange in their use is the inability to predict the amount of limitation inability to predict the amount of limitation that will be produced. that will be produced.

Surgery For SubluxationSurgery For Subluxation And Dislocation And Dislocation

The indications for surgery include a The indications for surgery include a disabling recurrent dislocation and disabling recurrent dislocation and longstanding dislocation not responsive longstanding dislocation not responsive to closed manipulations and other to closed manipulations and other nonsurgical treatment.nonsurgical treatment.

Acute dislocation and habit dislocation Acute dislocation and habit dislocation with significant psychologic influence with significant psychologic influence are rarely indications for surgery. are rarely indications for surgery.

There are three broad categories of There are three broad categories of procedures such are: procedures such are:

Designed to limit translation Designed to limit translation

To eliminate blocking factors in the condylar To eliminate blocking factors in the condylar path of closure or both. path of closure or both.

Limiting translation are anchoring, blocking & Limiting translation are anchoring, blocking & myotomy procedures.myotomy procedures.

The procedures, that eliminate blocking The procedures, that eliminate blocking factors in the condylar path of closure include factors in the condylar path of closure include diskectomy and eminectomy.diskectomy and eminectomy.

The combination procedures are The combination procedures are condylotomy, condylectomy,high condylotomy, condylectomy,high condylectomy, and lateral pterygoid myotomy condylectomy, and lateral pterygoid myotomy with diskectomy. with diskectomy.

Procedures to limit translationProcedures to limit translation ANCHORIN'G PROCEDURES:ANCHORIN'G PROCEDURES:

Anchoring procedures reduce or eliminate Anchoring procedures reduce or eliminate the anterior or translational motion of the the anterior or translational motion of the condyle.condyle.

The operations described in the literature The operations described in the literature include include capsulorrhaphy, capsular plication capsulorrhaphy, capsular plication ligamentopexy, flap secured to the capsule, ligamentopexy, flap secured to the capsule, autogenous and alloplastic slingsautogenous and alloplastic slings between between the condyle and zygomatic process securing the condyle and zygomatic process securing the disk to the capsule and tragus cartilage, the disk to the capsule and tragus cartilage, anchoring process to the zygomaanchoring process to the zygoma

Rehn used a I x 6 cm Rehn used a I x 6 cm deepidermized skin deepidermized skin flap from the occipital flap from the occipital region based on cranial region based on cranial periosteum tunneled periosteum tunneled and secured to the and secured to the capsule to augment a capsule to augment a capsulorrhaphycapsulorrhaphy. . Neiden modified Neiden modified Rehn's procedure by Rehn's procedure by using a temporal fascia using a temporal fascia flap in a similar flap in a similar manner. manner.

Gordon used fascia Gordon used fascia lata lata transplantstransplants secured secured through a vertical hole in through a vertical hole in the zygomatic process the zygomatic process near its base and another near its base and another horizontal hole in the horizontal hole in the condyle anteriorly to condyle anteriorly to inhibit anterior movement inhibit anterior movement of the condyle.of the condyle.He also removed the disk He also removed the disk before placing the sling. before placing the sling. Georgiade & Merrill Georgiade & Merrill modified this technique modified this technique by by utilizing wide Dacron utilizing wide Dacron suturessutures and not and not performing a diskectomy performing a diskectomy

Blake, believed that the Blake, believed that the suprahyoid musclessuprahyoid muscles were were important in mandibular important in mandibular dislocation and advised dislocation and advised that the mandible be that the mandible be limited more anteriorly.limited more anteriorly.He ligated the coronoid He ligated the coronoid process to the zygomatic process to the zygomatic arch.arch.Laskin, successful cases in Laskin, successful cases in which the which the lateral pterygoid lateral pterygoid muscle was detached & muscle was detached & sheet of silicone rubbersheet of silicone rubber was secured over the was secured over the pterygoid fossa of the pterygoid fossa of the condyle to prevent condyle to prevent reattachment. reattachment.

BLOCKING PROCEDURESBLOCKING PROCEDURESBlocking or arthroereisis proceduresBlocking or arthroereisis procedures to to interfere with translation are designed interfere with translation are designed to to create an obstacle to the condyle in create an obstacle to the condyle in its opening path.its opening path.

The operations in this category inculde The operations in this category inculde soft tissues and bony procedures:soft tissues and bony procedures:

The latter increase the height The latter increase the height of of the the articular eminence by articular eminence by osteotomies, osteotomies, bone grafts, & metal implants.bone grafts, & metal implants.

Soft TissueSoft Tissue Konjetzny surgically creates a closed lock by Konjetzny surgically creates a closed lock by

the disk .the disk . Konjetzny's procedure produces fixation of Konjetzny's procedure produces fixation of

the disk in an anterior position (closed lock).the disk in an anterior position (closed lock).The posterior ligament of the disk is released The posterior ligament of the disk is released

and the anterior attachment is preserved.and the anterior attachment is preserved. The disk is pulled anteriorly and inferiorly The disk is pulled anteriorly and inferiorly

and is anchored vertically in front of the and is anchored vertically in front of the condyle by suturing it condyle by suturing it to to the lateral pterygoid the lateral pterygoid muscle inferiorly and muscle inferiorly and to to the capsule laterally. the capsule laterally.

BonyBony

Foged,emphasize that there is a Foged,emphasize that there is a loss loss and flattening of the articularand flattening of the articular eminenceeminence in patients with recurrent in patients with recurrent and habitual dislocation and they and habitual dislocation and they advocated the rebuilding of the advocated the rebuilding of the eminence eminence to to create a block create a block to to condylar motion.condylar motion.

Mayer, resected a 1.5 cm Mayer, resected a 1.5 cm segment of the zygomatic segment of the zygomatic archarch and grafted it into a and grafted it into a furrow he created in the furrow he created in the articular eminence.articular eminence. Lindemann, made an Lindemann, made an oblique osteotomyoblique osteotomy to to increase the height of the increase the height of the articular tubercle. articular tubercle. Bone of the tubercle and Bone of the tubercle and eminenceeminence was tilted was tilted inferiorly and anteriorly. inferiorly and anteriorly. He also supplemented this He also supplemented this by excision of capsular by excision of capsular tissues & tissues & replacing the replacing the excised tissues with a excised tissues with a dermal graft.dermal graft.

Gossere &Dautry The Gossere &Dautry The zygomatic arch is cut zygomatic arch is cut vertically in front of the joint vertically in front of the joint and lowered.and lowered.Resistance to forward glide of Resistance to forward glide of the condylethe condyle is provided by a is provided by a bony abutment placed bony abutment placed directly anterior to the directly anterior to the condyle and firmly attached condyle and firmly attached to the zygomatic bone.to the zygomatic bone.Posteriolythis pedicled bonePosteriolythis pedicled bone of the lateral tubercle and of the lateral tubercle and arch is stable and more arch is stable and more effective than free bone effective than free bone grafts to the eminence.grafts to the eminence.

Eliminating Blocking Factors In The Eliminating Blocking Factors In The Condylar PathCondylar Path

Operations have been designed to Operations have been designed to eliminate obstacles in the condylar eliminate obstacles in the condylar path that may either trigger a path that may either trigger a dislocation or mechanically prevent dislocation or mechanically prevent reduction of the condyle into the reduction of the condyle into the glenoid fossa glenoid fossa

The two procedures which accomplish The two procedures which accomplish this are diskectomy and eminectomy.this are diskectomy and eminectomy.

DISKECTOMYDISKECTOMY

Diskectomy has been Diskectomy has been advocated by Ashurst & advocated by Ashurst & Axhausen for Axhausen for recurrent recurrent dislocation.dislocation. Lexer modified the Lexer modified the approach by using an approach by using an interpositional adipose interpositional adipose tissue graft.tissue graft.Boma,Silver and Simon Boma,Silver and Simon used dlskectomy for this used dlskectomy for this condition but combined it condition but combined it with with lateral pterygoid lateral pterygoid myotomy. myotomy.

EMINECTOMYEMINECTOMY

Eminectomy is an Eminectomy is an operation currently used to operation currently used to correct correct recurrent recurrent dislocationdislocationEminectomy first described Eminectomy first described by Myrhaug & Irby has by Myrhaug & Irby has been a commonly used been a commonly used procedure for procedure for chronic chronic subluxation and subluxation and dislocationdislocation..The reason for the success The reason for the success of this operation may be of this operation may be due to greater freedom of due to greater freedom of movement between the movement between the condyle, disk, and reduced condyle, disk, and reduced eminence.eminence.

Limited condylar motionLimited condylar motion can also be attributed to can also be attributed to the formation of the formation of adhesions between the adhesions between the disk and reduced disk and reduced eminence and ligament eminence and ligament scarring.scarring.

EminectomyEminectomy exposes exposes marrow and leaves a marrow and leaves a roughened surface. roughened surface. Hemorrhage and Hemorrhage and increased friction increased friction between articular between articular surfaces can lead to surfaces can lead to adhesions and limitation. adhesions and limitation.

Combined procedures to eliminate Combined procedures to eliminate blocking and limit translation blocking and limit translation

The procedures in this category include: lateral The procedures in this category include: lateral pterygoid myotomy with diskectomy, pterygoid myotomy with diskectomy, condylotomy, and condylectomy.condylotomy, and condylectomy.

Lateral Pterygoid Myotomy With Diskectomy:Lateral Pterygoid Myotomy With Diskectomy:

The combination of lateral pterygoid myotomy The combination of lateral pterygoid myotomy and diskectomy first described by Boman and diskectomy first described by Boman restricts anterior gliding movement of the restricts anterior gliding movement of the condylecondyle and diminates obstruction caused by and diminates obstruction caused by the disk.the disk.

Silver & Simon advocated this combination for Silver & Simon advocated this combination for surgical treatment of surgical treatment of recurrent dislocation recurrent dislocation

CondylotomyCondylotomy

Condylotomy was first Condylotomy was first described by Ward described by Ward elt elt for treatment of painful for treatment of painful joints with joints with inter inter derangement.derangement. It has been advocated It has been advocated by Poswillo &Tasanen by Poswillo &Tasanen advocate the intraOral advocate the intraOral approach to treat approach to treat subjects with subjects with recurrent recurrent dislocation.dislocation.

Condylotomy is an osteotomy through the Condylotomy is an osteotomy through the condylar neck which is performed through condylar neck which is performed through an an extra oral approach.extra oral approach.

A similar osteotomy may be achieved by an A similar osteotomy may be achieved by an intraoral approach.intraoral approach.

Both procedures release the condyle and Both procedures release the condyle and allow it to displace anteriorly & inferiorly.allow it to displace anteriorly & inferiorly.

The procedures reduce the strength of The procedures reduce the strength of lateral pterygoid muscle by shortening it lateral pterygoid muscle by shortening it while while allowing it to remain functional. allowing it to remain functional.

CondylectomyCondylectomyHigh condylectomyHigh condylectomy is a more is a more conservative operation with conservative operation with preservation of most of the preservation of most of the lateral pterygoid muscle and a lateral pterygoid muscle and a less significant less significant decrease in decrease in vertical height of the ramus.vertical height of the ramus. It is preferred over It is preferred over condylectomy and it will also condylectomy and it will also eliminate conflicts with the disk eliminate conflicts with the disk & eminence.& eminence.Scar formation and partial loss Scar formation and partial loss of lateral pterygoid muscle will of lateral pterygoid muscle will limit but not eliminate forward limit but not eliminate forward glide of the mandible .glide of the mandible .

A A complete condylectomycomplete condylectomy has the great has the great disadvantage of producing facial and disadvantage of producing facial and occlusal deformity.occlusal deformity.

It can be considered a procedure that both It can be considered a procedure that both restricts forward motion and removes restricts forward motion and removes blocking factors.blocking factors.

The lateral pterygoid muscle is sacrificed, The lateral pterygoid muscle is sacrificed, ramus is shortened, producing an ramus is shortened, producing an open-bite open-bite deformity and retrusion of the mandibledeformity and retrusion of the mandible..

The blocking effect of the condyle on the The blocking effect of the condyle on the disk or eminence is removed in this disk or eminence is removed in this procedure. This operation is a last resort procedure. This operation is a last resort when other operations have failed or in when other operations have failed or in certain long-standing dislocations. certain long-standing dislocations.